MEDICAID 101
What’s the difference between Medicaid and Medicare?
Medicaid is a needs-based program with financial eligibility limits. Medicare is a federal health insurance program for people who have worked and paid into the system.
Does Medicaid transfer from one state to another?
Yes and no. Medicaid programs differ in each state, although the basic program - health care coverage primarily for children and people with disabilities - offers the same essential benefits and will typically transfer. Other Medicaid programs, particularly Medicaid HCBS Waivers, do NOT transfer and people must reapply and navigate a waiting list when they move.
Is Medicaid a federal program or a state program?
Both. Medicaid is subject to federal law and jointly funded by federal and state governments. It is operated by the state, but only after the state gets federal approval for its administrative plan.
How do Medicaid HCBS Waivers differ from basic Medicaid?
Medicaid Home and Community-Based Service (HCBS) Waivers are intended to provide home care services for people who might otherwise end up in an institution, like a nursing home. Unlike the basic Medicaid program, HCBS Waivers have a cap on enrollment and each state can design its own eligibility criteria.
Is Medicaid one program or many?
Many. Medicaid programs may differ in financial and clinical eligibility, types of services offered, who administers the program, how services are funded, and whether there is a cap on enrollment.
Which agency in Florida operates Medicaid?
The Florida agency with oversight of all Medicaid programs is the Agency for Health Care Administration (“AHCA”). However, AHCA contracts with state agencies and private entities to administer different Medicaid programs or tasks within a program. Still, the buck stops with AHCA.
MEDICAID 201
Basic Medicaid
The Medicaid program common to all states provides health care benefits like hospitalization and out-patient care to low-income people with disabilities, children, and pregnant women. Some states expanded this program to cover adults who are living in extreme poverty, but Florida has not yet opted to do so.
Basic Medicaid is also known as “State Plan” Medicaid (because the details of state oversight are set out in a “State Plan”), “regular” Medicaid, or “straight” Medicaid. In Florida, most people get basic Medicaid through a managed care plan; in that case it is called “Managed Medical Assistance” or “MMA.”
HCBS Waivers
All HCBS Waivers must be approved by the federal government after submission of a detailed application by the state. Most states, like Florida, have more than one, with different Waivers covering different populations.
One of the biggest issues with HCBS Waivers is the cap on enrollment. Because enrollment can’t exceed the cap, there is often a long waiting list. Getting off the waiting list depends on how the list is prioritized and that differs for each program.
Managed Care
When a Medicaid program is operated through a managed care model, the state contracts with organizations, like private health insurance companies, to act as the gatekeepers for authorization of services. These “managed care plans” also put together a network of providers to deliver the services or supplies. The state is still ultimately responsible for compliance with the law, but the plans are making the care decisions.
In Florida, most people on basic Medicaid have managed care plans. So do all the enrollees in the Long-Term Care (LTC) Waiver.
You are not alone if you don’t understand Medicaid
"… almost unintelligible to the uninitiated." ~ Chief Justice Roberts in Wos v. EMA, 133 S. Ct. 1391 (2013), quoting Justice Friendly
“ … an aggravated assault on the English language, resistant to attempts to understand it.” ~ Friedman v. Berger, 547 F.2s 724 (CA2 1976)
“… this Court is not the first to observe that America’s system of care for its aging, indigent population is literally the most complex in the world.” ~ Del. Div. of Health & Soc. Serv. v. US Dept. of HHS, 665 F. Supp. 1104 (D. DE 1987)